A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions?

Taking the infant's vital signs every 2 hr

Counting the number of wet diapers every shift

Weighing the infant at the same time every day

Measuring the infant's head circumference twice per day

Answer and Explanation

The Correct Answer is C

A. Taking the infant's vital signs every 2 hr: Monitoring vital signs every 2 hours can help assess the infant’s general condition and detect changes in heart rate and blood pressure, which can indicate changes in hydration status. However, it might not be sufficient alone to monitor fluid status.

B. Counting the number of wet diapers every shift: Tracking the number of wet diapers is an effective way to monitor the infant's fluid output and hydration status. An increase in wet diapers typically indicates improved hydration. This is a practical and non-invasive method for assessing the effectiveness of IV therapy in infants.

C. Weighing the infant at the same time every day: Daily weights are a critical measure of fluid balance in infants. A consistent daily weight check provides a direct and accurate assessment of the infant’s hydration status and response to IV therapy.

D. Measuring the infant's head circumference twice per day: Measuring head circumference is not relevant for monitoring hydration status. It is typically used to assess growth and development in infants, not fluid balance or response to IV therapy.

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Correct Answer is D

Explanation

A. "I will provide low-fat meals for my child.": Children with cystic fibrosis need a high-calorie, high-fat diet to meet their increased energy needs and to help with growth and development due to malabsorption issues.

B. "I will restrict the amount of salt in my child's meals.": Children with cystic fibrosis tend to lose more salt through sweat and often require additional salt in their diet.

C. "I will put my child in daycare to ensure that she socializes with other children.": While socialization is important, children with cystic fibrosis are at higher risk for respiratory infections and should avoid environments where they are more likely to be exposed to pathogens.

D. "I will make sure my child washes her hands before eating.": Hand hygiene is crucial for preventing infections, which are a significant risk for children with cystic fibrosis due to their compromised lung function.

A. "I will immediately report irregular respirations." B. "I will immediately report a respiratory rate of 28." C. "IWA count the baby's respirations for 30 seconds and multiply by two." D. "I will count the baby's respirations by observing abdominal movements."

Correct Answer is D

Explanation

A. "I will immediately report irregular respirations." Irregular respirations can be normal in infants, as their breathing patterns are often irregular. Immediate reporting is not typically necessary unless there are other signs of distress.

B. "I will immediately report a respiratory rate of 28." A respiratory rate of 28 is low for a 1-month-old infant, but immediate reporting depends on the overall clinical picture and other signs of distress. Normal respiratory rates for this age are usually between 30-60 breaths per minute.

C. "I will count the baby's respirations for 30 seconds and multiply by two." While this method is used for older children and adults, it’s not ideal for infants due to their irregular breathing patterns. Counting for a full minute provides a more accurate assessment.

D. "I will count the baby's respirations by observing abdominal movements." This is correct. In infants, respiration is primarily diaphragmatic, making abdominal movements a reliable indicator of respiratory rate.

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A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions?

Nursing Test Bank

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